Looking at common lower- extremity problems and what

to do about them

Common Pedal ComplaintsSkin Problems: nails, blisters, calluses, wounds and misc. dermatology

Bone Problems: tumors, deformities, fractures

Arthritities: bunions, hammertoes, general arthritis, sero-negative arthropathies

Pain Syndromes: enthesiopathies, acute trauma, causalgia and RSD

Diabetic Concerns: vasculopathy, neuropathy, immunopathy and attendant problems

Skin ProblemsIngrown nails:

Use antibiotics if cellulitis is seenSurgical removal of offending border:

anaesthesia of lidocaine (with or without epi) and Marcaine buffered with NaCO3

if one border involved, consider if the nail is worth saving

Phenol matrixectomy, saline flush

dress with topical abx and gauze sponge, not Band-Aid™

Epsom salt soaks to draw out drainage

Skin ProblemsCalluses:

Tinea:

Tell patients not to use medicated pads

palliative care for comfort: trimming, cushions and wide toe-box shoes

radiograph of foot may show underlying bone spur, indicating a progressive problem

Typical presentation is flaky (T. rubrum)

rule out psoriasis, eczema

bullous type is T. mentagraphytes

rule out contact dermatitis

Bone Problems

TumorsGout

FracturesNone are common in

the foot

if seen, thinkosteochondroma, enchondroma, unicameral bone cyst, multiple myeloma

Control diet (tyromines)

use anti-inflammatories

use colchicine

get blood work

possible joint tap

If seen in digits, ‘buddy splint’

other bones need casting, ORIF

Arthritities

Bunions

And hammertoes

Emphasize accommodation (shoes with wide toe-boxes, padding, trimming of corns, lesions)

Sometimes surgery is the only choice, but it requires time off the surgical extremity

The patient who is--or is suspected of being--a poor candidate for surgery needs accommodation

Usually indicative of overall foot-type

ArthrititiesGeneral osteoarthritis

Rheumatoid (sero +)

Sero-negative:Reiter’s

Psoriatic

Irritable bowel

Anklyosing spondlilitis

Gonococcal arthritis

SLE (systemic lupuserythematosis)

Behçet’s syndrome

Heel paintypically in the hypermobile

flatfoot patient

rule out recent trauma

rule out fracture

rule out radiculopathy

rule out sero-negative arthropathies

Pain Syndromes

Heel PainActually a nerve entrapment

syndrome, the spur means nothing

Rule out radiculopathy, sero-negative causes Entheseopathies

Inferior calcaneus

Insertion of Achilles with calcification

Diabetic Concerns

� Transfer lesions

�Mallet-toe lesions

� intertrigenous lesions

� hammertoe lesions

� xerotic skin problems

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Diabetic Concerns

3 changes seen:neuropathyangiopathyimmunopathy

Importance:if you can’t feel your feet, you can’t

feel if they’re injured

if you injure your feet, it will take less force to cause ulcers

if you ulcerate the skin, it will be harder to heal

if the ulceration reaches bone, it may mean amputation

the amputation level may be proximal to injury to heal site

it is unusual to have one amputation not lead to others

3 types of neuropathy:autonomicmotorsensory

When to refer out to your local foot guyNail infections with bone involvement,

which have been treated, but have recurred, or you feel unsure about treating

Wounds which need debridement, off-loading or more than simple care

Bone problems (tumors, fractures, arthritic deformities)

Unremitting pain recalcitrant to conservative treatment

Biomechanical instability (hyperpronation), or gross deforming changes to the structure of the foot/ankle (tendon or ligament strains, sprains or tears)

Yearly diabetic evaluation and assessment

When you’re fed-up and don’t want to deal with it anymore!

Thank Y o u